AMA THALASSAEMIA CENTRE, AWAN PLAZA, MANDIAN, ABBOTTABAD.

APPLICATION FOR MEMBERSHIP

NAME: [ Mr, Mrs, Miss ]-------------------------------------------------------------------------------
FATHER’S / HUSBAND’S NAME: ------------------------------------------------------------------
OCCUPATION: -----------------------------BLOOD GROUP:--------------------------------------
PERMANENT ADDRESS:---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PHONE NUMBER: OFF:------------------- RES: ---------------- MOBILE:----------------------
MEMBERSHIP FEE: Please Tick:
Yearly Membership Rs. 200/= [     ]  @@@   Life Membership: Rs.2000/= [    ]

DATE:----------------------------------		Signature--------------------------
Please Note: Cheques or Pay Orders may please be made available to: 
Chairman, A MA, Awan Plaza, Mandian, Abbottabad 22044.
AMA Account No. 277, Muslim Commercial Bank, Ayub Medical College, Abbottabad. Please submit 2 Id. Card size photographs & Copy of National Id. Card  with this form.

SPONSOR A THALASSAEMIC CHILD:
A Thalassaemic Child needs Blood Transfusion every month. The minimum monthly expenditure at a single transfusion is approximately as follows:
Blood Bag with Transfusion Set : Rs. 85/= , Hemoglobin Estimation: Rs. 15/=, Grouping and Cross matching Rs. 50/=, Screening tests for Hepatitis B , HIV Rs. 200/= Minimum . So Rs. 350/= per blood transfusion and Rs. 4200/= per year for 12 blood transfusions. 
I would like to sponsor a Thalassaemic child and I am enclosing Cheque / DD of Rs.4200/- for yearly expenditure for one patient.

Signature:						Date:			 		

AMA HEALTH CARD.

Name of the Student:------------------------------------------------------------------
Father’s Name: --------------------------------------------------------------------------
Class / Grade: ------------- School: --------------------------------------------------
Sex: ------ Age: ------- Years------ Months OR  Date of Birth-----------------

MEDICAL EXAMINATION:

Height: --------------- Feet:-------------- Inches: Weight: ------------------- Kg.
GROWTH CHART: ---------------------------------------------------------------------

Anemia: ------- Clubbing: --------- Koilonychia: --------- Jaundice: -------

ORO-DENTAL HYGIENE: -------------------------------------------------------------
G.I. TTACT: -------------------------------------------------------------------------------
Resp. TRACT: ---------------------------------------------------------------------------
C.V.S.: --------------------------------------------------------------------------------------
C.N.S.:--------------------------------------------------------------------------------------
Any other finding: ---------------------------------------------------------------------

EYE EXAMINATION:

VISION LEFT EYE: -------------------------VISION RIGHT EYE:-------------------

COVER TEST: ---------------------------------------------------------------------------

REMARKS: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------

					Signature of the Doctor: ----------------------------
					Date of Examination :---------------------------------